sirolimus gel 0.2% — Blue Cross Blue Shield of Montana

Initial criteria

• 1. The requested quantity (dose) does NOT exceed the program quantity limit OR
• 2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
• A. BOTH of the following:
• 1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
• 2. There is support for therapy with a higher dose for the requested indication OR
• B. BOTH of the following:
• 1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
• 2. There is support for why the requested quantity cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program limit OR
• C. BOTH of the following:
• 1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
• 2. There is support for therapy with a higher dose for the requested indication

Approval duration

BCBSIL: 12 months; All other plans: Initial 12 weeks; Renewal 12 months